CLINICAL ARTICLE

Effect of maternal fasting for religious beliefs on fetal sonographic

ndings and neonatal outcomes
Kerem D. Seckin
a,
, Mahmut I. Yeral
b
, Mehmet F. Karsl
c
, Ismail B. Gultekin
c
a
Department of Gynecology and Obstetrics, Bingol Solhan Government Hospital, Bingol, Turkey
b
Department of Gynecology and Obstetrics, Giresun Bulancak Government Hospital, Giresun, Turkey
c
Department of Gynecology and Obstetrics, Sami Ulus Women and Childrens Health Training and Research Hospital, Ankara, Turkey
a b s t r a c t a r t i c l e i n f o
Article history:
Received 7 November 2013
Received in revised form 4 February 2014
Accepted 7 April 2014
Keywords:
Doppler ultrasonography
Maternal fasting
Neonatal outcomes
Ramadan
Objective: To investigate the effects of long-lasting maternal fasting on fetal biometry, amniotic uid volume, fetal
Doppler parameters, and neonatal outcomes. Methods: The present study, conducted at Solhan State Hospital,
Bingol, Turkey, between July and August 2013 recruited 82 healthy and otherwise normal pregnant women
with a gestational age of 29 weeks or more who were fasting for at least 20 days. The control group comprised
87 healthy non-fasting women matched for maternal age, parity, gestational age. Fetal parameters were mea-
sured at the beginning and the end of the fasting month. Perinatal outcomes were comparedbetweenthe groups.
Results: There were no signicant differences between the groups in fetal biometry, fetal Doppler parameters, or
neonatal outcomes. In the fasting group, however, there was a signicantly greater decrease in amniotic uid
index during the fasting period (P b 0.001). The number of women who initially had a normal amniotic uid
measurement and subsequently developed oligohydramnios was also signicantly higher in the religious fasting
group (P b 0.05). Conclusion: Fetal development, Doppler parameters, and neonatal outcomes were not signi-
cantly affected in healthy fasting women; however, there was a signicant association between fasting and am-
niotic uid index. These ndings mandate more frequent follow-up visits for this group of women.
2014 International Federation of Gynecology and Obstetrics. Published by Elsevier Ireland Ltd. All rights reserved.
1. Introduction
Ramadan is a holy month among Muslims and is known as the
month of fasting. It is always the ninth month according to the Islamic
calendar, and fasting with no eating or drinking lasts for several hours
for each day of this month. For centuries, religious Muslim women
have maintained Ramadan fasting even when pregnant and, although
they believe that it is not harmful to their fetus, they ask for advice dur-
ing prenatal visits.
Religious fasting is particularly observed among populations in
the eastern regions of Turkey [13]. Fasting may lead to dehydration
and metabolic instability [4,5]. Sufcient amniotic uid and utero-
placental circulation are mandatory for fetal development and well-
being [6]. Previous studies foundthat fetal development [7,8] anduterine
artery ow patterns [9] were not affected during the fasting period, but
another study reported a signicant increase in abnormal biophysical
scores [10].
The aim of the present study was to investigate the effects of reli-
gious fasting on fetal biometry, fetal Doppler, amniotic uid index
(AFI), and neonatal outcomes among pregnant women in their third
trimester.
2. Materials and methods
The present study was conducted between July 8 and August 8,
2013, among pregnant women attending a prenatal clinic at Solhan
State Hospital, Bingol, Turkey. The local ethics committee gave study
approval, and written consent was obtained from all participants.
The study group comprised women with singleton pregnancies of
29 weeks or more of gestation who were fasting for at least 20 days.
The control group comprised non-fasting pregnant women matched
for maternal age, parity, and gestational age. The exclusion criteria
were maternal systemic disease, history of previous surgery, and high-
risk pregnancies such as fetal anomaly, intrauterine fetal growthretarda-
tion, polyhydramnios, preeclampsia, and gestational diabetes mellitus.
All sonographic measurements were performed by the same sonog-
rapher toward the end of the daily fasting period (between 18:00 and
19:00). An initial examination was carried on the rst fasting day, and
a second examination was done on the last day of the fasting month.
International Journal of Gynecology and Obstetrics 126 (2014) 123125
Corresponding author at: Bingol Solhan Government Hospital, Department of
Gynecology and Obstetrics, Solhan, Bingol 12700, Turkey. Tel.: +90 506 5152715; fax:
+90 426 7112483.
E-mail address: doga_seckin@hotmail.com (K.D. Seckin).
http://dx.doi.org/10.1016/j.ijgo.2014.02.018
0020-7292/ 2014 International Federation of Gynecology and Obstetrics. Published by Elsevier Ireland Ltd. All rights reserved.
Contents lists available at ScienceDirect
International Journal of Gynecology and Obstetrics
j our nal homepage: www. el sevi er . com/ l ocat e/ i j go
A DC-3 diagnostic ultrasound instrument (Mindray, Schenzen,
China) was used for fetal measurements. The parameters were
biparietal diameter (BPD), abdominal circumference (AC), femur length
(FL), amniotic uid index (AFI) and accompanying weeks. The Hadlock
1 formula was used to estimate fetal weights [11]. Doppler ow mea-
surements included middle cerebral artery (MCA) and umbilical artery
(UA) systole and diastole.
The maternal characteristics of the participants were recorded.
The participants were followed-up throughout the third trimester, and
delivery outcomes were recorded.
Statistical analysis was done with SPSS version 17 (IBM, Armonk,
NY, USA). Data were compared between the two groups by an indepen-
dent sample t test. A P value of less than 0.05 was considered to be sta-
tistically signicant.
3. Results
In total, 169 pregnant women were included in the study: 82 in the
fasting group, and 87 in the control group. Maternal age, parity, mater-
nal weight at the beginning of pregnancy, gestational age, and maternal
weight gain during pregnancy were similar between the 2 groups
(Table 1).
The mean period of fasting in the study group was 23 2.6 days.
The mean fasting time was 18.7 hours (1720 hours) in the study
group and 3.9 hours (0.78.0 hours) in the control group (P b 0.01).
At the end of the fasting month (Ramadan), the changes in BPD, AC,
and FL, and fetal weight gain (FWG) were similar between the groups.
There was no signicant difference between the 2 groups in Doppler pa-
rameters (MCA and UA S/D ratios). However, the AFI measured at the
end of the fasting period was signicantly lower than that measured
at the beginning of the fasting period for women in the fasting group
(P b 0.001) (Table 2).
There were no differences between the two groups in neonatal pa-
rameters such as birth weight, gestational age at time of delivery, admis-
sion to the neonatal intensive care unit (NICU), and type of delivery.
However, the number of patients who initially had a normal amniotic
uid measurement and subsequently developed oligohydramnios was
signicantly higher in the religious fasting group than in the non-
fasting group (Table 3).
4. Discussion
Religious fasting during Ramadan is one of the principal rules of Is-
lamic belief. This Islamic rule is frequently obeyed, especially among
populations in the eastern region of Turkey. The fasting hours change
each year because the Islamic calendar is lunar [12,13].
Studies have investigated the effects of long-lasting dehydration
during fasting [2,14], and most have found no association with Apgar
scores, AFI, birth weight or gestational age at the time of delivery
[1517]. The effects of fasting on fetal biometry, AFI, and Doppler pa-
rameters (MCA, UA and uterine artery) have also been studied, and
fasting was again recorded to have no negative impact on any of these
parameters [8,10].
Clinical studies of Doppler parameters found that the ratio of MCAto
UAwas more sensitive thanMCADoppler measurements alone [1820].
In the present study, however, MCA, UA, and MCA/UA ratio Doppler
measurements showed no signicant difference between the fasting
and non-fasting groups. Similar Doppler ndings were reported by
Hizli et al. [21].
In the present study, fetal biometric parameters such as BPD, AC, FL
and FWG were compared with no signicant differences between the
two groups, similar to the results of Moradi [22]. Whereas Mirghani
et al. [10] found that the frequency of cesarean delivery and NICU ad-
mission was higher in a fasting group than in a non-fasting group,
there was no signicant difference in these outcomes between the
two groups in the present study. Fetal birth weights and gestational
age at time of delivery were also similar between the two groups.
Inprevious studies onfastingduringRamadan, theaveragetimeof fasting
was 915 hours, as compared with 18.7 hours (range 1720 hours) in
the present study. Fasting was performed between 04:00 and 08:00 in
a hot climate (average temperature 35 C) for at least 20 days. In con-
trast to the studies of Dikensoy et al. [8] and Kamyabi et al. [23] there
was a signicant decrease in AFI in the fasting group as compared
with the non-fasting group. Because the Doppler parameters were
within normal limits, the decrease in AFI might be related to maternal
dehydration.
Obstetricians should be concerned about fetal well-being because of
the decreased AFI and low biophysics scores in the third trimester,
which in turn lead to a need for more frequent prenatal visits for
these pregnant women. The observed lack of effect of fasting on neona-
tal outcomes despite the decrease in AFI might be related to the small
study population.
In summary, there was no association of religious fasting (prolonged
cessationof foodanduidintake) withfetal parameters suchas biometry,
Doppler ow parameters, and neonatal outcomes among pregnant
women. However, there was a signicant association between fasting
Table 1
Comparison of maternal characteristics between the fasting and non-fasting group.
Characteristic Fasting group
(n = 82)
Non-fasting group
(n = 87)
P value
Age, y 24 4.2 (1929) 26.1 5.9 (2032) 0.41
Parity 2.5 0.9 2.2 1.1 0.56
Primary maternal weight, kg 58.6 9.4 60.2 11.2 0.78
Weight gain, kg 5.4 1.86 6.2 1.49 0.63
Fasting, h 18.7 (1720) 3.9 (0.78.0) b0.001
Gestational age, wk 34.1 (3040) 35.2 (2939) 0.12
Values are given as mean SD or mean (range) unless stated otherwise.
Table 2
Comparison of ultrasonographic indices between the fasting and non-fasting group.
a
Ultrasonographic
index
Fasting group
(n = 82)
Non-fasting group
(n = 87)
P value
BPD, mm 9.17 1.5 9.41 1.3 0.26
Age-BPD, wk 3.7 0.31 3.7 0.37 0.18
FL, mm 8.62 1.79 8.6 1.84 0.81
Age-FL, wk 3.6 0.4 3.7 0.3 0.12
AC, mm 41.7 6.7 41.3 5.2 0.45
Age-AC, wk 3.6 0.43 3.6 0.36 0.25
AFI 20.1 11.2 11.5 6.4 b0.001
FWG, g 485.4 162 461.8 84 0.16
UA Doppler, S/D 2.45 0.37 2.41 0.35 0.86
MCA Doppler, S/D 4.71 0.72 4.56 0.8 0.98
MCA/UA ratio, S/D 1.95 0.43 1.92 0.42 0.72
Abbreviations: BPD, increase in biparietal diameter; Age-BPD, increase in gestational
age of biparietal diameter; FL, increase in femur length; Age-FL, increase in
gestational age of femur length; AC, increase in abdominal circumference; Age-AC,
increase in gestational age of abdominal circumference; FWG, fetal weight gain; MCA,
middle cerebral artery; UA, umbilical artery; S/D, systolic to diastolic ratio.
a
Values are given as mean SD unless stated otherwise.
Table 3
Fetal outcomes and type of delivery.
a
Outcome Fasting group
(n = 82)
Non-fasting group
(n = 87)
P value
Birth weight, g 3089 300 3450 352 0.09
Gestational age at delivery, wk 37.2 (3640) 38.6 (3739) 0.11
NICU admission 4 (4.8) 3 (3.4) 0.48
Cesarean delivery 20 (24.3) 22 (25.2) 0.92
Occurrence of oligohydramnios 20 (23.8) 6 (7.3) 0.03
Abbreviation: NICU, neonatal intensive care unit.
a
Values are given as mean SD, mean (range), or number (percentage) unless stated
otherwise.
124 K.D. Seckin et al. / International Journal of Gynecology and Obstetrics 126 (2014) 123125
anddecreasedAFI, andfasting shortenedthe interval for oligohydramnios
development. Therefore, close prenatal surveillance is warranted for
these women.
Conict of interest
The authors have no conicts of interest.
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